Renal carcinoma discovered incidentally by arteriography during evaluation for hypertension

A 10-Year Old Girl with Resistant Hypertension without Significant Indication of an Underlying Renal Cell Carcinoma, Misdiagnosed as Malaria

Patient: Female, 10

Final Diagnosis: Arterial hypertension secondary to renal cell carcinoma

Symptoms: Recurrent headaches • excessive sweating • anorexia • weight loss • easy fatigability

Medication: —

Clinical Procedure: Nephrectomy

Specialty: Pediatrics and Neonatology

Elevated Serum Creatinine and a Normal Urinalysis: A Short Differential Diagnosis in the Etiology of Renal Failure

OBJECTIVE

The diagnosis of renal failure with a normal urinalysis represents a short differential diagnosis that has not been characterized in the literature. This study was designed to identify the specific disease states that encompass this interesting renal condition.

MATERIAL

The Regenstrief database, which is an electronic medical record containing inpatient laboratory and other clinical data for patients admitted to Wishard Memorial Hospital, was utilized to provide data for this study.

METHODS

The database was culled to provide data for hospitalized patients admitted between March 1, 1992, and March 1, 2001, with the concurrent findings of a serum creatinine greater than or equal to 2 mg/dL, a normal urinalysis, and diagnoses of obstructive uropathy, multiple myeloma, prerenal azotemia, hypertensive nephrosclerosis, interstitial nephritis, renal vascular disease, hypokalemic nephropathy, and hypercalcemia, as identified by their corresponding ICD-9 codes.

RESULTS

A search of the Regenstrief database yielded a total of 190,343 patient admissions. There were 515 patient admissions with renal failure and a concurrent normal urinalysis. The largest specific diagnostic categories within this group were hypertension and prerenal azotemia.

CONCLUSIONS

An elevated serum creatinine and normal urinalysis present a short differential for the etiologies of renal failure and include such entities as hypertensive nephrosclerosis, prerenal azotemia, obstructive nephropathy, interstitial nephritis, renal vascular disease, and various electrolyte abnormalities. An awareness of these specific disease states may lead to an earlier diagnosis and more effective treatment of renal failure.

Paraneoplastic hypertension associated with renal oncocytoma: management with cryoablation

Paraneoplastic hypertension associated with a renal oncocytoma is an unreported syndrome. We report a unique case of a patient with multidrug-resistant hypertension who was found to have a solitary renal mass. Cryoablation was performed and resulted in an immediate and dramatic decrease in blood pressure. Histologic review of intraoperative biopsy specimens revealed findings consistent with renal oncocytoma. To our knowledge, this is the first report of hypertension in the setting of a renal oncocytoma, with subsequent improvement of this paraneoplastic syndrome after cryoablation.

[Paraneoplastic syndrome in renal cell carcinoma]

Renal cell carcinoma associated paraneoplastic symptoms include constitutional symptoms as well as specific metabolic and biochemical abnormalities. These are present in up to 40% of patients with renal cell carcinoma during the course of the disease. This report provides information on the most common manifestations and their therapy; some rare variants are also mentioned. The importance of paraneoplasia lies partly in the fact that paraneoplastic symptoms may be the precursor of either primary or recurrent disease. The presence of paraneoplastic manifestations does not necessarily imply a poor prognosis or metastatic disease.

Blood pressure and site-specific cancer mortality: evidence from the original Whitehall study

Studies relating blood pressure to cancer risk have some shortcomings and have revealed inconsistent findings. In 17 498 middle-aged London-based government employees we related systolic and diastolic blood pressure recorded at baseline examination (1967–1970) to the risk of cancer mortality risk at 13 anatomical sites 25 years later. Following adjustment for potential confounding and mediating factors, inverse associations between blood pressure and mortality due to leukaemia and cancer of the pancreas (diastolic only) were seen. Blood pressure was also positively related to cancer of the liver and rectum (diastolic only). The statistically significant blood pressure–cancer associations seen in this large-scale prospective investigation offering high power were scarce and of sufficiently small magnitude as to be attributable to chance or confounding.

Renal cell carcinoma and malignant phase hypertension

Many cross-sectional and follow-up studies of large numbers of patients with hypertension have demonstrated an increased prevalence and mortality from renal cancer. We report the details of three patients with renal cell carcinoma from a series of 254 consecutive patients with malignant phase hypertension, an excess over the expected number reported from several large published series with non-malignant hypertension. In view of this excess we investigated the prevalence of hypertension in a series of 192 consecutive patients who presented with a diagnosis of renal cell carcinoma, in comparison with a local unselected population screening survey. Hypertension was found in 43% of the renal carcinoma patients and 20% of the local population, also a clear excess. The mechanism of the association between renal cancer and malignant and non-malignant hypertension is unclear.

Diuretics may increase risk of renal cell carcinoma

The risk for kidney cancer was examined in a Danish cohort of 192,133 people on a hospital discharge register who had been given a diagnosis of hypertension, heart failure, or edema, and were presumed to be probable users of diuretics. The subjects were identified from 1977 to 1987 and followed-up for cancer through 1987. A total of 10,630 cancers was observed. While the risk for all cancers was increased slightly (standard mortality ratio [SMR] = 122, 95 percent confidence interval [CI] = 120-124), the risk for renal cell carcinoma was more than doubled (SMR(men) = 221, CI = 192-253; SMR(women) = 246, CI = 213-283). Increased risks were found in all age groups, and, although surveillance bias was present initially, the risk increased consistently in the years following discharge. Risk estimates for individuals discharged with hypertension were similar to those for the total cohort. Use of diuretics was validated in a random sample of 100 individuals. More than 70 percent were taking diuretics at the time of discharge. The increased risk for renal cell carcinoma in this cohort may indicate either that diuretics are involved in the etiology of renal cell carcinoma or that the risk can be attributed to confounders, including smoking, which affect risk for both the discharge diagnosis and renal cell carcinoma.

Late determinants of cancer

The paper reviews some findings on the frequency of latent carcinoma. Latent carcinomas are found much more frequently in the prostate, than would be expected from mortality or incidence data. The same applies to neuroblastomas in the adrenal cortex in infants. The problem has not been studied in detail in other organs. A satisfactory explanation of spontaneous regression of human cancers or the variable disease-free survival time of cancer patients has not been found. It is concluded that defence mechanisms of paramount importance exist, and need to be studied. Recent reports on serum retinol and serum cholesterol are reviewed since these are both lower in people who later develop cancer. Much more knowledge is needed but these phenomena could be linked.

Ectopic renal cell carcinoma: pathologists problem

Renal cell carcinoma (hypernephroma) rarely develops as a primary tumor outside the normal confines of the kidney. Although many reports of so-called extrarenal hypernephroma may be found in the literature, very few cases appear to fulfill modern criteria for tumors of true renal origin. Strict criteria for the diagnosis of true extrarenal hypernephroma are proposed, and a case that partially conforms to these standards is presented.

Increased incidence of renal cell carcinoma with hypertension

Of 276 patients who underwent evaluation to determine the cause of hypertension 2 were found to have unsuspected renal cell carcinoma. This prevalence of 0.73 per cent is 16 times higher than expected for an age-matched population. Both patients exhibited abnormalities of plasma renin activity before radical nephrectomy but they remained hypertensive postoperatively. The data suggest an unexplained association between hypertension and renal cell carcinoma. Furthermore, abnormalities on excretory urograms in hypertensive people should be defined by selective renal arteriography.